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Nursing care plan
Risk for injury related to diminished/decreased vision
Short term goal: The patient will be able to perform activity of daily living without injuring self
Long term goal: the patient will demonstrate improvement quality of life with minimal to no risk for injury by incorporating life style and home environment modifications throughout hospitalization
Question
List 20 nursing interventions with rationales for the nursing diagnosis above based on the scenario
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- Case Study She is not sleeping and acts like her ear hurts HPI: 10-mo-old girl, who is scheduled to be seen for an “ear infection.” Her mother reports that she was awake a lot during the night. “I think she was pulling at her right ear. Amoxicillin does not work for her.” She also reports that last week she had a runny nose and a mild cough treated with Tylenol. Hasn’t been eating as well as usual. Baby does not go to daycare, although her mother does meet other mothers and babies in the park on nice days, and they play together. She did that over the past week. She also reports that no one else in the household has been sick. Baby was full term, normal vaginal delivery with good Apgar scores. Still breastfeeding. She has a positive history for an ear infection at age 2 mo (treated with Amoxicillin), at 3 mo (treated with Bactrim), and at 4 mo (also treated with Bactrim). A mild effusion was noted at her 6-mo well child visit, but she was not treated, as she was asymptomatic at that…1 2 3 4 5 6 CASE STUDY ON CATARACT Mrs. Janet Donald is a 66-year-old woman who lives alone in her own home. Her son found her unconscious on the floor approximately four hours after sustaining a fall. She was admitted to the Mount Hope hospital for overnight observation. On admission, she had a small bump on her forehead but was awake, alert and oriented to time, place and person. When interviewed about the incident, she said that she has been experiencing blurring of her vision and complained of seeing glares and halos whenever she looks at bright lights even for a split second. However, she ignored these, attributing them to tiredness. She admits that her vision is very foggy and she is having problems seeing as clear as she use to in earlier years. She claims that she under estimated the placement of the mat and her foot got entangled in it while exiting the bath. Assessment shows that the lens in her eyes looked cloudy. Mrs. Donald was reviewed by the ophthalmologist on call and…HISTORY OF PRESENT ILLNESS: Edith Martens is a 66-year-old female who is recovering fromviral pneumonia. When her daughter came to check on her, she found Edith in bedcomplaining of weakness, constant fatigue and abdominal pain.For the past few days, Edith has been complaining of thirst and frequent urination. She alsoreports that she cannot see very well. Edith has lost approximately 4 lbs over the last week.Her daughter brought Edith to the ER. PAST HISTORY: There is a history of osteoarthritis that responds well to ASA. Edith wasdiagnosed with Type 2 diabetes approximately two years ago. She takes glyburide 10 mg everymorning before breakfast and is on an 1800 calorie diet, which she follows closely. SOCIAL HISTORY: Edith has lived alone since the death of her husband. She is not physicallyactive; her activities consist of light housework and occasional shopping trips. FAMILY HISTORY: Edith’s father had Type 2 diabetes complicated by peripheral vasculardisease. He died at the age of…
- HISTORY OF PRESENT ILLNESS: Edith Martens is a 66-year-old female who is recovering fromviral pneumonia. When her daughter came to check on her, she found Edith in bedcomplaining of weakness, constant fatigue and abdominal pain.For the past few days, Edith has been complaining of thirst and frequent urination. She alsoreports that she cannot see very well. Edith has lost approximately 4 lbs over the last week.Her daughter brought Edith to the ER. PAST HISTORY: There is a history of osteoarthritis that responds well to ASA. Edith wasdiagnosed with Type 2 diabetes approximately two years ago. She takes glyburide 10 mg everymorning before breakfast and is on an 1800 calorie diet, which she follows closely. SOCIAL HISTORY: Edith has lived alone since the death of her husband. She is not physicallyactive; her activities consist of light housework and occasional shopping trips. FAMILY HISTORY: Edith’s father had Type 2 diabetes complicated by peripheral vasculardisease. He died at the age of…SubjectiveChief Complaint: “I have pain in all of my joints, a swollen left knee, and stiffness every morning.” HPI: Janet Hobbs is a 58-year-old woman who presents to her rheumatologist with generalized arthralgias, a swollen left knee, and morning stiffness. These symptoms have been occurring with increasing severity for the past several weeks. She presented with similar symptoms 3 months ago, at which time her drug regimen was changed from methotrexate and NSAID therapy to her current regimen below. PMH: RA × 6 years S/P, hysterectomy 4 years ago, HTN × 10 years FH: Father died from complications after a traumatic fall at age 65. Mother died of a hip fracture and pneumonia at age 78. No siblings. SH: Housewife; married for 32 years; has two grown children with no known medical problems. Denies alcohol or tobacco use. Volunteers in the community extensively, but has been doing less in the past 2 months. Meds: Hydrochlorothiazide 25 mg PO Q AM, Norvasc 10 mg PO once daily, Nabumetone…Case study: Amelia is a 68-year-old woman who was brought into ED by herneighbour. She woke this morning at 0600 hours with a 5/10 headache.At 0700 she called her neighbour and asked her to bring her to hospitalwhen she began to feel weak, and her headache increased to 7/10. Atthis time, one side of her face began to “feel strange”.She has past medical history of Atrial fibrillation (AF), hypertension (HT)and dyslipidaemia which she manages with Apixaban 2.5mg BD, Sotolol80mg daily, Amlodipine 5mg daily, Irbesartan/hydrochlorothiazide300/25mg daily, Rosuvastatin 10mg daily.Amelia used to smoke 20 cigarettes/day but states she quit 5 years ago.When she was brought into ED, she told staff that she did not take hermedications this morning as she was too distracted by her increasingheadache.You are assigned to care for Amelia. As you are about to enter her room,you overhear Amelia crying to her neighbour, explaining that she isworried as her mother had died of a stroke. Vital signs:•…